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Aetna considers the following procedures medically necessary for treatment of varicose veins when the following criteria are met: Surgical ligation including subfascial endoscopic perforator vein surgery SEPS or endovenous ablation procedures are considered medically necessary for the treatment of incompetent perforating veins with vein diameter measured by recent ultrasound of 3. Initially, endovenous ablation therapy of the first vein and of the second and subsequent veins in each affected extremity is considered medically necessary when criteria are met.

Additional endovenous ablation therapy may also be necessary for treatment of accessory saphenous veins as noted above, Thrombophlebitis der ICD-10 Code. These procedures are considered cosmetic for all other indications. The term endovenous catheter ablation EVCA is a non-specific term that refers to the several catheter based minimally invasive alternatives to surgical stripping such as radiofrequency endovenous occlusion VNUS procedure and endovenous Thrombophlebitis der ICD-10 Code ablation of the saphenous vein ELAS.

In assessing the medical necessity of EVCA, reference should be made to the specific technique that is being employed. Aetna considers liquid or foam sclerotherapy endovenous chemical ablation e. Since ultrasound-monitored or duplex-guided techniques for sclerotherapy have not been shown to definitively increase the effectiveness or safety of this procedure, these tests are only considered medically necessary when initially performed to determine the extent and configuration of varicose veins.

Ultrasound- or radiologically guided or monitoring techniques are of no proven value when performed solely to guide the needle or introduce the sclerosant into the varicose veins, Thrombophlebitis der ICD-10 Code.

The number of medically necessary sclerotherapy injection sessions varies with the number of anatomical areas that have to be injected, as well as the response to each injection.

A set Thrombophlebitis der ICD-10 Code injections is defined as multiple sclerotherapy injections during a treatment session. Ambulatory phlebectomy or transilluminated powered phlebectomy is considered experimental and investigational for treatment of junctional reflux as these procedures have not been proven to be effective for these indications.

Ambulatory phlebectomy and the TriVex system is considered cosmetic for veins less than 2. Transilluminated Retinathrombose Augen phlebectomy has not been proven to be superior to other methods of varicose vein removal. Therefore, the TriVex procedure should be billed as any other varicose vein removal procedure.

Initially, up to two multiple stab phlebectomy incisions in each affected extremity i. Additional multiple stab phlebectomy incisions are considered medically necessary for persons with persistent or recurrent symptoms. A set of stab phlebectomy incisions is defined as multiple stab phlebectomy incisions during a treatment session. Aetna considers photothermal sclerosis also referred to as an intense pulsed light source, e. YAG laser has been shown to be effective for the treatment of telangiectasias and reticular veins, treatment of these small veins is considered cosmetic.

Aetna considers endomechanical or mechanicochemical ablation MOCA e. For endoluminal cryoablation also referred to as cryofreezing, Thrombophlebitis der ICD-10 Code, cryostripping, cryosurgery, cryotherapy for varicose veins, Thrombophlebitis der ICD-10 Code, see CPB - Cryoablation uyftcvyuffwtzvdutrywwxtx.

Varicose veins are a common condition. In most persons, varicose veins do not cause symptoms other than poor cosmesis. Varicose vein surgery is one of the most commonly performed cosmetic procedures in the United States. Most varicose veins do not require medical treatment Tapley et al, In some cases, however, the circulation may be hindered enough to cause swelling of the foot and ankle, discomfort, a tingling sensation, or a feeling of heaviness.

For most people with varicose veins, Thrombophlebitis der ICD-10 Code, wearing specially fitted elastic stockings is all that is needed. The stockings should be carefully fitted to the individual, providing the most pressure in the lowest part of the leg. The stockings should be put on when first arising in the morning, preferably before getting out of bed. Exercise such as walking or cycling also helps promote better circulation from the lower part of the body.

Resting with the legs elevated will help promote circulation; in contrast, sitting with the legs crossed can aggravate the condition. A substantial proportion of varicose vein symptoms respond to conservative management. Conservative management consisted of lifestyle advice relating to exercise, leg elevation, management of weight and diet, and the use of compression hosiery. In the surgical arm of the trial patients received the same lifestyle advice but also underwent surgical treatment, consisting of flush ligation of sites of reflux, stripping of the long saphenous vein and multiple phlebectomies, as appropriate.

Although a greater proportion of patients assigned to surgery plus lifestyle advice at relieving symptoms at 1 year, approximately one-third of subjects assigned to conservative management reported some relief from conservative management with compression hosiery.

At 2 years, there was no significant difference in symptom improvement between groups assigned to conservative management versus surgery. The authors posited that the lack of significant difference in symptomatology between groups at 2 years may have been due to cross-overs, with 7 patients in the conservative management group opting for surgery in year 1 and 37 patients opting for surgery in year 2.

The study also found that persons assigned to surgery plus lifestyle advice had a greater improvement in cosmesis and quality of life than persons assigned to lifestyle advice alone, although it is not known whether improvements in quality of life were primarily related to improvements in cosmesis versus reductions in symptomatology. Weaknesses of the study included a substantial loss to follow-up in all groups. Fifteen of the patients assigned to surgery either refused surgery in favor of conservative management or declined surgery due to fitness.

Of the remaining patients who underwent surgery, 43 were lost to follow up by the first year, Thrombophlebitis der ICD-10 Code. Of subjects assigned to conservative treatment, Thrombophlebitis der ICD-10 Code, 21 were lost to follow-up by the first year. In addition, a substantial proportion of persons assigned to conservative management reported improvements in cosmesis. An editorialist noted that the short follow-up of subjects assigned to surgery may result in an underestimate of the costs and an exaggeration of the benefits of surgery van Rij, The editorialist noted, however, that most recurrences are diagnosed later than 3 years.

Focusing on the short-term may lead to an under-estimate of cost and an over-estimate of benefit. In patients with varicose veins, leg pain may be associated with superficial thrombophlebitis or venous leg ulcers. In evaluating the role of varicose vein surgery in treatment of these conditions, the effectiveness of varicose vein surgery must be compared to conservative management.

If the patient is suffering from superficial thrombophlebitis, conservative management is indicated. According to available guidelines, uncomplicated superficial thrombophlebitis is usually treated symptomatically with heat, Thrombophlebitis der ICD-10 Code analgesia, non-steroidal anti-inflammatory drugs NSAIDsand Beeswax von Varizen stockings SCHIN, Treatment should continue until symptoms have completely subsided usually 2 to 6 weeks to subside but the thrombosed vein may be palpable and tender for months.

More severe thrombophlebitis, as indicated by the degree of pain and redness and the extent of abnormality, should be treated by bed rest with elevation of the extremity and application of hot, wet compresses.

Leg ulcers arising from venous problems are called venous varicose or stasis ulcers. The main conservative treatment has been to apply a firm compression garment bandage or stocking to the lower leg in order to help the blood return back up the leg.

Cullum et al conducted a meta-analysis of the literature on the effectiveness of compression bandaging Thrombophlebitis der ICD-10 Code stockings in the treatment of varicose leg ulcers. The authors concluded that compression increases ulcer-healing rates compared with no compression. The authors also found that multi-layered systems are more effective than single-layered systems. High compression is more effective than low compression but there are no clear differences in the effectiveness of different types of high compression.

In a meta-analysis, Nelson et al found circumstantial evidence of the benefit of compression in reducing recurrence of varicose ulcers. The authors also noted that recurrence rates may be lower in high compression hosiery than in medium compression hosiery and therefore patients should be offered the strongest compression with which they can comply. According to a systematic review of the evidence, pentoxifilline has also been shown to be effective for treatment of venous leg ulcers Nelson et al, According to the systematic evidence review, compression has been shown to prevent venous leg Thrombophlebitis der ICD-10 Code. The effectiveness of vein surgery for prevention or treatment of venous ulcers is "unknown" Nelson et al, Thrombophlebitis der ICD-10 Code, Despite many years of experience, there is still a disappointingly high recurrence rate of varices because many patients are inadequately investigated before treatment.

As it has been shown that physical examination alone is unreliable, pre-treatment Doppler or Duplex ultrasound examination must be performed for localization of the sites of incompetence to allow the individualization of the treatment strategy for each patient.

Photographs or office diagrams may be helpful in assessing the size and extent of the varices. Under established guidelines, the basic tenet of successful treatment is to eliminate the primary and Thrombophlebitis der ICD-10 Code sources of the reflux. These sources are usually a nearby perforator, or most often a major junction that causes redirected venous return through veins with intact valves. Almost all cases of painful varicosities Thrombophlebitis der ICD-10 Code associated with junctional reflux.

Although varicosities can occasionally be present in the absence or reflux, there is a lack of evidence from reliable clinical studies of the effectiveness of sclerotherapy in relieving symptomatic varicosities not associated with junctional reflux.

Although sclerotherapy can be used to treat visible subcuticular veins i. Doppler ultrasound is often used in conjunction with other non-invasive physiologic testing to characterize the anatomy and physiology of the varicose vein network prior to injection or surgical intervention. However, Thrombophlebitis der ICD-10 Code scans are also sometimes utilized during the sclerotherapy procedure itself. Their purported usefulness in this regard includes the localization of deep or inaccessible injection sites, such as when there are extensive networks of large deep varicosities, areas of significant reflux between superficial and deep systems, or risks to arterial structures.

However, these indications have not been scientifically validated. There is little evidence, in the form of randomized prospective clinical trials, to support that ultrasound makes a significant difference in optimizing outcome or decreasing complications, from sclerotherapy for varicose veins, when compared to non-ultrasound-guided techniques.

If saphenofemoral reflux lasting longer than ms is present, Thrombophlebitis der ICD-10 Code, the diameter of the great saphenous veins GSV is recorded 2.

The size of the vein has been correlated with the presence of significant saphenous reflux. The compliant GSV adjusts its luminal size to the level of transmural pressure, and measurement of its diameter has been shown to reflect the severity of hemodynamic compromise in limbs with GSV reflux.

In a cohort study, Navarro, et al. The authors stated that they found that the GSV diameter proved to be a relatively accurate measure of hemodynamic impairment and clinical severity in a model of saphenofemoral junction and GSV incompete ce, predicting not only the absence of abnormal Thrombophlebitis der ICD-10 Code, but also the presence of critical venous incompetence.

A GSV diameter of 5. Ligation alone usually results in a high recurrence rate of the varicose vein, which may then require sclerotherapy treatment MSAC, Visible subcuticular veins i.

Ambulatory phlebectomy AP also known as microphlebectomy is a minimally invasive procedure performed under local anesthesia, and is an accepted outpatient therapy for the removal of varicose veins. Non-refluxing varicose veins on the surface of the leg, not including the saphenous veins, may be treated as an outpatient procedure under local anaesthetic using ambulatory phlebectomy MSAC, Thrombophlebitis der ICD-10 Code, However, recurrence rates can be high if the source of the reflux is not treated MSAC, The junctions themselves can not be treated with simple phlebectomy as junctional reflux must be addressed by endovenous ablation methods or rarely by surgical ligation and stripping MSAC, ; Weiss, Patients can ambulate immediately after AP.

Complications associated with AP include blister formation, localized thrombophlebitis, Thrombophlebitis der ICD-10 Code, skin necrosis, hemorrhage, and persistent edema.

The use of broad compression pads following AP reduces hemorrhage and enhances resorption. The TriVex System transilluminated powered phlebectomy is an alternative method of providing ambulatory phlebectomy.

This entails endoscopic resection and ablation of the superficial veins using an illuminator and a "powered vein rejector", a small powered surgical device. In this procedure, veins are marked with a magic marker. In order to enhance visualization of the veins, a bright light is introduced Thrombophlebitis der ICD-10 Code the leg through a tiny incision. The powered vein rejector, which has a powered oscillating end, is then introduced to cut and dislodge the veins, Thrombophlebitis der ICD-10 Code.

The pieces of vein are then gently retrieved by suction down a tube.


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Aetna considers LMWHs experimental and investigational for all other indications, including in any of the following clinical settings, because the current medical literature does not provide enough scientific evidence that their use is associated with better health outcomes as compared to UFHs:.

Aetna considers desirudin experimental and investigational for the following indications not an all-inclusive list. Aetna considers argatroban Argatroban Injection in the outpatient setting medically necessary for prophylaxis of cerebral thrombosis, Thrombophlebitis der ICD-10 Code, and thrombosis in individuals with heparin-induced thrombocytopenia HITand treatment of cerebral thrombosis, and thrombosis in individuals with HIT. Aetna considers argatroban experimental and investigational for the following indications not an all-inclusive list:.

Low molecular weight heparins are fragments or fractions of conventional unfractionated heparin that produce anticoagulation when administered subcutaneously.

The products are prepared using a wide variety of methods. Chromatographic techniques have been employed to separate various fractions from unfractionated heparin.

Thrombophlebitis der ICD-10 Code techniques include molecular exclusion, stearic exclusion, ion exchange, and affinity chromatography. Chromatographic methods of fractionation are effective but give a minimal yield. Chemical or enzymatic depolymerization of heparin produces much higher yields and is more commercially acceptable. Low molecular weight heparin fractions may contain between four and 25 distinct molecular fragments.

Most low molecular weight heparin fractions have a molecular weight between and daltons. Each heparin fragment may be comprised of two to 50 monosaccharide units and each exhibits a varying degree of activity. Fragmin dalteparin sodium is a low molecular weight heparin. It has antithrombotic properties which inhibits coagulation Factor Xa and thrombin by means of antithrombin, while it slightly affects activated partial thromboplastin time.

Innohep tinzaparin sodium is a low molecular weight heparin which exhibits antithrombotic properties. It inhibits reactions through plasma protease inhibitor, antithrombin, which is responsible for blood clotting including fibrin clots formation. Neutralization of Factor Xa disrupts the blood coagulation cascade, which inhibits thrombin formation and thrombus development. Arixtra is technically not a LMWH.

In DecemberThrombophlebitis der ICD-10 Code, Celgene issued a Dear Healthcare Professional letter describing a controlled clinical study suggesting that Innohep may increase the risk for death, compared to UFH when used to treat elderly patients with renal insufficiency.

It recommended consideration of alternatives to Innohep when treating these patients for deep vein thrombosis DVT with or without pulmonary embolism PE. Standard UFHs are preferable for the prevention and treatment of venous thrombosis and the prevention of venous thromboembolism in low-risk patients, and for maintaining coronary patency after thrombolytic treatment for acute myocardial infarction.

There is no convincing evidence that LMWHs have an improved benefit to risk ratio over standard UFHs in patients with arterial thrombosis or with symptomatic pulmonary embolism. The most significant advantage of LMWHs is that they raise the possibility that selected patients with venous thrombosis might be suitable candidates for treatment at home, Thrombophlebitis der ICD-10 Code advance that would reduce cost and improve patient convenience.

Studies have shown that LMWH does not cross the placenta, has no teratogenic effects, and is as effective as traditional heparin. Preliminary evidence suggests that there is no greater risk of bone demineralization, and that LMWH decreases risks of thrombocytopenia and hemorrhagic complications.

Patients with unstable angina and non-Q wave myocardial infarction may sustain a small amount of myocardial loss but have significant amounts of viable, yet ischemic, myocardium, placing them at high-risk for future cardiac events.

The benefit of LMWHs in acute coronary syndromes has been validated in several clinical trials. The results of the TIMI trial indicate that LMWHs are effective in reducing major ischemic outcomes in patients with unstable angina and non-Q wave myocardial infarction.

The ESSENCE study showed that combination anti-thrombotic therapy with enoxaparin plus aspirin is more effective than UFH plus aspirin in decreasing ischemic outcomes in patients with unstable angina or non-Q-wave myocardial infarction in the early 30 days phase, and that the lower recurrent ischemic event rate seen with the LMWH is achieved without an increase in major bleeding.

The subcutaneous administration, the lack of a need for laboratory tests, Thrombophlebitis der ICD-10 Code, better predictability of the anticoagulant effect and better tolerance are powerful arguments favoring LMWH for use in unstable angina and infarction without Q wave. The requirement for prolonged oral anti-platelet or LMWH treatment in ambulatory patients after an acute coronary event remains to be evaluated. Trials of longer-term therapy with LMWHs are in progress.

The Thrombophlebitis der ICD-10 Code ACCP Consensus Conference on Antithrombotic Therapy stated that available evidence indicates that enoxaparin is ineffective in preventing restenosis following coronary angioplasty.

Furthermore, LMWH is not recommended for the treatment of acute heparin-induced thrombocytopenia Hirsh et al, In the initial treatment of venous thromboembolism, LMWH is administered once- or twice-daily. A once-daily treatment regimen is more convenient for the patient and may optimize home treatment. However, it is not clear whether a once-daily treatment regimen is as safe and effective as a twice-daily treatment regimen. Thus, the decision to treat a person with a once-daily regimen will depend on the evaluated balance between increased convenience and the potential for a lower efficacy.

On behalf of the American Society of Clinical Oncology, a panel of experts Lyman et al, performed a comprehensive systematic review of the medical literature on the prevention and treatment of venous thrombo-embolism VTE in cancer patients. Following discussion of the results, the panel drafted recommendations for the use of anti-coagulation in patients with malignant disease.

Recommendations of the American Society of Clinical Oncology VTE Guideline Panel include i all hospitalized cancer patients should be considered for VTE prophylaxis with anti-coagulants in the absence of bleeding or other contraindications; ii routine prophylaxis of ambulatory cancer patients with anti-coagulation Thrombophlebitis der ICD-10 Code not recommended, with the exception of patients receiving thalidomide or lenalidomide; iii patients undergoing major surgery for malignant disease should be considered for pharmacologic thromboprophylaxis; iv LMWH represents the preferred agent for both the initial and continuing treatment of cancer patients with established VTE; and v the impact of anti-coagulants on cancer patient survival requires additional study and can not be recommended at present.

A total of 1, consecutive patients were included in this trial. The data and safety monitoring board prematurely stopped the day heparin group after the second interim analysis.

Combined incidence of asymptomatic proximal DVT, Thrombophlebitis der ICD-10 Code, symptomatic VTE, and all-cause mortality primary efficacy end point and combined incidence of major and clinically relevant bleeding events primary safety end point were recorded. All patients had bilateral whole-leg ultrasonography at the end of the allocated prophylactic regimen or earlier if indicated.

All patients with normal findings were followed for 3 months, and none was lost to follow-up. The cumulative incidence of major or clinically relevant bleeding events was 0. The authors concluded that in patients undergoing knee arthroscopy, prophylactic LMWH for 1 week reduced a composite end point of asymptomatic proximal DVT, symptomatic VTE, and all-cause mortality more than did graduated compression stockings. This treatment effect was mainly evident in patients having meniscectomy-related procedures, Thrombophlebitis der ICD-10 Code.

In an editorial that accompanied the afore-mention paper, Thrombophlebitis der ICD-10 Code, Hull stated that the findings by Camporese et al encourages the use of LMWH thromboprophylaxis in knee arthroscopy patients undergoing meniscectomy, Thrombophlebitis der ICD-10 Code.

The aggregate evidence supports this recommendation. In a review on prevention of thalidomide- and lenalidomide-associated thrombosis in myeloma, Thrombophlebitis der ICD-10 Code International Myeloma Working Group Palumbo et al, noted that the incidence of VTE is more than 1 in 1, annually in the general population and increases further in cancer patients.

The risk of VTE is higher in multiple myeloma MM patients who receive thalidomide or lenalidomide, especially in combination with dexamethasone or chemotherapy. Myeloma-related risk factors include diagnosis and hyper-viscosity. Venous thrombo-embolism is very high in patients who receive high-dose dexamethasone, doxorubicin or multi-agent chemotherapy in combination with thalidomide or lenalidomide, but not with bortezomib.

Low-molecular-weight heparins is also recommended for all patients receiving concurrent high-dose dexamethasone or doxorubicin. Full-dose warfarin targeting a therapeutic INR of is an alternative to LMWH, although there are limited data in the literature with this strategy. Klein and colleagues stated that the immunomodulatory drugs thalidomide and lenalidomide have enhanced activity in patients with MM.

Based on this evidence, it is recommended that VTE prophylaxis be prescribed in these patients. However, the optimal prophylaxis remains controversial. All patients received prophylactic anti-coagulation with low LMWH. None of the other 44 patients had clinical signs of thrombosis or embolism and none of all patients experienced complications or side effects Thrombophlebitis der ICD-10 Code to anti-coagulation.

These findings indicated that prophylactic anti-coagulation with LMWH is Thrombophlebitis der ICD-10 Code and effective. Kaandorp et al noted that aspirin and LMWH are prescribed for women with unexplained recurrent miscarriage, with the goal of improving the rate of live Gelverband venöser Ulzera, but limited data from randomized, controlled trials are available to support the use of these drugs.

They then randomly assigned them to receive daily 80 mg of aspirin plus open-label subcutaneous nadroparin at a dose of 2, IU, starting as soon as a viable pregnancy was demonstrated80 mg of aspirin alone, or placebo. The primary outcome measure was the live-birth rate, Thrombophlebitis der ICD-10 Code. Secondary outcomes included rates of miscarriage, obstetrical complications, and Thrombophlebitis der ICD-10 Code and fetal adverse events.

The proportions of women who gave birth to a live infant were Among women who became pregnant, the live-birth rates were The authors concluded that neither aspirin combined with nadroparin nor aspirin alone improved the live-birth rate, as compared with placebo, among women with unexplained recurrent miscarriage.

Abstracts from major gastro-enterological meetings were searched to identify research published in abstract form only. Each author independently reviewed potentially relevant trials to determine their eligibility for inclusion based on the criteria identified above. The Cochrane Risk of Bias tool Thrombophlebitis der ICD-10 Code used to assess study quality. Laser-Behandlung von Krampfadern Ufa Preise published in abstract form only were included if the authors could be contacted for further information.

A data extraction form was developed and used to extract data from included studies. At least 2 authors independently extracted data. Any disagreements were resolved by consensus, Thrombophlebitis der ICD-10 Code.

Data were analyzed on an intention-to-treat basis. The primary outcome was induction of remission, as defined by the studies. Low-molecular-weight heparin administered subcutaneously showed no benefit over placebo for any outcome, including clinical remission, and clinical, endoscopic, Thrombophlebitis der ICD-10 Code, or histological improvement. High-dose LMWH administered via an extended colon-release tablet demonstrated benefit over placebo for clinical remission odd ratio [OR] 2.

Low-molecular-weight heparin was not beneficial when added to standard therapy for clinical remission, clinical improvement, endoscopic remission or endoscopic improvement. Low-molecular-weight heparin was well-tolerated but provided no significant benefit for quality of life. More patients assigned to UFH had rectal hemorrhage as an adverse event.

When administered by extended colon-release tablets, LMWH was more effective than placebo for treating out-patients with mild-to-moderate disease. The same benefits were not seen when LMWH Krampfadern in Russland administered subcutaneously at lower doses.

Management of APS centers on attenuating the procoagulant state while balancing the risks of anti-coagulant therapy, Thrombophlebitis der ICD-10 Code. Cases of recurrent thromboses and obstetric complications occur despite optimum therapy. Alternative therapies for refractory cases are subject to disparity among clinicians due to the current lack of clinical evidence present.

This review addressed the current management strategies for refractory thrombotic and obstetric cases and future therapeutic interventions. The role and current clinical evidence of using long-term LMWH as an alternative to warfarin therapy for refractory thromboses Thrombophlebitis der ICD-10 Code evaluated. Potential alternatives for thromboses including statins, hydroxychloroquine, rituximab were reviewed as well as the additional avenues to target in the future as the pathogenic mechanisms of APS were unveiled.

The optimal management for refractory obstetric APS cases is subject to controversy. This review focused and assessed the current evidence for the uses of low-dose prednisolone, intravenous immunoglobulin and hydroxycholoroquine in obstetric cases. The authors concluded that the treatment modalities for the management of refractory APS require further clinical evidence. The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, Thrombophlebitis der ICD-10 Code, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions.

Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular and hospital neurology. In patients who received low-dose LMWH, there was no hematoma enlargement at 72 hours, day 7, or day 21 compared with the compression stocking group.


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